REPORT OF TWO CASES OF PUERPERAL FEVER. BY JOHN O. POLAK, M.D., CLINICAL ASSISTANT TO THE CHAIR OF OBSTETRICS, NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL J INSTRUCTOR IN PRACTICAL OBSTETRICS AND ASSISTANT TO THE CHAIR OF HISTOLOGY AND PATHOLOGY, LONG ISLAND COLLEGE HOSPITAL. FROM THE MEDICAL NEWS, November 12, 1892. [Reprinted from The MEDICAL News, November 12, 1892.] REPORT OF TWO CASES OF PUERPERAL FEVER. By JOHN O. POLAK, M.D., CLINICAL ASSISTANT TO THE CHAIR OF OBSTETRICS, NEW YORK POST- GRADUATE MEDICAL SCHOOL AND HOSPITAL; INSTRUCTOR IN PRACTICAL OBSTETRICS AND ASSISTANT TO THE CHAIR OF HISTOLOGY AND PATHOLOGY, LONG ISLAND COLLEGE HOSPITAL. * There is probably no disease so dreaded, alike by the profession and by the laity, and that has so vigor- ously resisted the assaults of thoughtful physicians, as childbed fever. It is not my purpose in this paper to attempt anexhaustive article on this subject, but sim- ply to illustrate, by the aid of the cases that I have selected, the indications to be combated in the treat- ment, and how to meet them. Acknowledgment of my indebtedness is due to Pro- fessor C. A. von Ramdohr, who, by his valuable counsel and timely suggestions, first led me to investigate this matter. Case I.—Jane R., aged twenty-one years, a prim- ipara was born in the United States; her condition during pregnancy being excellent. The presentation was cephalic, and all the pelvic measurements were diminished three-quarters of an inch. She was delivered by forceps April 17th, after having been in labor twenty- one hours and twenty minutes. The indications for inter- ference were as follows : Head engaged and stationary for three and a half hours ; pains frequent, paroxysmal, but powerless ; the fetal heart—which was heard on the 2 left side four inches below the umbilicus near the median line—becoming arhythmic, and rapidly increasing from 140 to 180 pulsations per minute. The operation was performed under careful antisepsis, though the cus- tomary ante-operation vaginal douche was, by some mistake, omitted. There was a successful delivery of a living male child. The mother did well until the fifth day (April 23d), when, toward evening, she was seized with rigors, followed by a rapid rise in temperature to 102.6°; with a pulse 88, full, and bounding. The urine was high-colored and small in amount. The lochia were arrested, but there was no fetor. On careful palpa- tion, there was no evidence of metritis or perime- tritis. Some tympanitic distention existed; the tongue was heavily coated; there was frontal headache, and the face was flushed; the skin was hot and dry. Calomel (gr. v) was given, followed by dram-doses of magnesium sulphate every hour until free catharsis resulted. A milk-diet was prescribed. Quinine sulphate gr. xx, in a single dose, was given, to exclude the possi- bility of the fever being of malarial origin. On April 25th I was asked to see the patient by my colleague, Dr. Gibbs. At that time her morning tem- perature was io4°in mouth; pulse 92 and compressible; a chill had recurred, and the expression was anxious; the tongue dry and very heavily coated. Still there was no evidence of local inflammation. The lochia were completely suppressed, though the involution had pro- gressed correspondingly with the period of the puerpe- rium. I had no doubt as to the case being one of general septicemia. The bowels had been moved freely by salines. No distention or tenderness of the abdomen was present. A vaginal douche of carbolic acid (5 per cent.) was given, and I advised whiskey, f every hour until the desired effect—i. e., lowered temperature, im- proved pulse, skin and tongue becoming moist, was produced. 3 On April 24th. p.m., the temperature was 102.6° ; the pulse 88, compressible; the tongue moistened about edges, but coated. Urination and watery movements had taken place. There was no tenderness over the uterus. The treatment was continued. On April 25th, noon, the patient was seen by Dr. von Ramdohr. The treatment was approved and continued. The patient looked more cheerful. The temperature was ioo°, the pulse 100, very compressible; the tongue and skin moist. On April 25th, 10 p.m., the temperature was 99.8° ; the pulse 95, volume improving. The milk-diet was con- tinued. The quantity of whiskey was reduced one- half. On April 26th, the countenance was cheerful; the tongue clean and moist; the pulse 69, of good quality ; the temperature 990; the lochia reappearing, and with- out odor. There was no tenderness of the uterus. The whiskey was diminished to f §j every three hours, and the milk-diet continued. On April 27th, the patient was still improving rapidly ; the pulse and temperature were normal. The diet was increased and stimulants were stopped. On April 29th (eleventh day) the patient sat up for two hours. Case II.—Maria M., a primipara; born in the United States. There were umbilical hernia the size of an egg, and varicose veins of the legs and labia. Her condition during the present pregnancy was very poor from the effects of influenza last January, and improper and nsufficient food. This patient was delivered by Dr. E. D. Gazzam, on June 16th, by version. The indications for interference were as follows : The mother’s temperature was 103.6° ; pulse 140, dicrotic. There was inertia of the uterus ! the head was not engaged ; the os uteri was the size 4 of a “double silver dollar.” Here, again, most perfect antisepsis as to the operator’s hands, arms, patient’s external genitals, etc., was carried out, but the ante- operation vaginal douche was again omitted. A living male child was delivered. The mother’s pulse was 116, of poor quality ; the temperature 103° at the close of the operation. On June 16th, at 11 p.m., the countenance was pale and anxious. Urination was practised in the recumbent position. The temperature was 99.8°; the pulse 92, rhythm and volume improved ; after-pains existed and there was tenderness over the uterus. Milk-diet was ordered, and of whiskey every three hours. On June 17th, at 4 p.m., the countenance was pale but contented; she had slept two hours, and urinated; the lochia were free and sweet; the uterus was six inches above pubes; the temperature 99.8°; the pulse 84. Milk-diet and stimulants were continued. On June 18th, at 9 A.M.,the countenance was anxious. She had urinated and the bowels had moved. She had slept four hours; the temperature was 103.40; and the pulse 120. The breasts were not secreting. The uterus was just below the umbilicus. Whiskey was given every hour. On June 18th, at 3 p.m., the temperature was 104.40; the pulse 140, very compressible, and of small volume; the tongue dry and coated; the facial expression anx- ious ; there was headache; restlessness; the skin was hot and dry; the lochia suppressed ; upon careful pal- pation no signs of local inflammation were present, ex- cept tympanitic distention of slight degree. I advised free catharsis by calomel, followed by dram-doses of mag- nesium sulphate every hour until a free watery move- ment was obtained, and that the amount of whiskey be increased to every hour. From this time convalescence began, and on June 27th the patient was sitting up and gaining strength. 5 From the foregoing cases, selected because of their typical histories, coupled with nnny other experiences, I draw the following conclusions : First. That there are two forms of puerperal fever: sapremia, a local condition due to retained membranes, placental tissues, blood-clots, etc.; in which, because of exposure to the bacteria of putrefaction, ptomaines are developed, setting up a local inflammation. The other form is general septicemia, and occurs usually after the fourth day. This is a general condition, with few, if any, local manifestations, and is due to the absorption of the pus-organisms. This latter class of cases is illus- trated by the foregoing histories. Second. That septicemia will and does occur even when the most careful attention has been paid to the hands of the operator, instruments, and external geni- tals ; from dislodgment of the bacteria in the vagina, either by hands or instruments, and so removing them from an acid secretion which renders them harmless to the alkaline secretion of the cervix, which acts as a culture-medium. Third. That, in my experience, septicemia can be prevented, even after the most difficult forceps-applica- tions and prolonged versions, by absolute antisepsis of the operator’s hands and instruments ; and, preceding the introduction of the hand or instrument into the uterus, by hot vaginal douches of mercuric chloride (i 13000) or creolin (2 per cent.). Again, after any form of instru- mental interference whatsoever, it is my custom to throw into the uterus large quantities of carbolic solution (5 per cent.), or creolin (1 per cent.), having a temperature of from 105° to 1 io° F.; followed by plain hot water, and using a fountain syringe ; and of late I have been leaving from 30 to 40 grains of iodoform in the shape of pencils, within the uterus, thus insuring continued asepsis. An- other suggestion that is worthy of consideration in cases in which sepsis is feared is the use of copious hot ene- 6 mata of Rochelle salts, or soap-suds immediately after labor, depleting the pelvic organs, and, consequently, proving valuable adjuvants in the prevention of sepsis. Fourth. That in our treatment of septicemia, local in- terference, such as continuous irrigation of the uterus, is of little or no value, as there is a general infection, not a local inflammation. Pyrexia and asthenia are the conditions to be combated; therefore, our treatment must be general, not local, as in cases of sapremia. Whiskey, or any form of alcohol, in heroic doses will meet both these indications. The temperature will drop, the pulse improve in quality and diminish in frequency, the tongue and skin will become moist, and restlessness will diminish. Fifth. That free catharsis with salines is a most im- portant aid in the management of these cases, by re- ducing the temperature and relieving the congestion of the pelvic organs and peritoneum, which frequently exists. In conclusion, let me say that septic fever in my opinion, is a preventable accident. Physicians too fre- quently ignore their responsibility, but the trouble can always be traced to some slip in the technique. The Medical News. Established, in 1843. A WEEKL YMEDICAL NEWSPAPER. Subscription, $4 00per Annum. The American Journal OF THE Medical Sciences. Established in J&20 A MONTHLY MEDICAL MAGAZINE. Subscription, $4.00 per Annum. COMMUTA TION RA TE, $7.30 PER ANNUM. LEA BROTHERS & CO PHILADELPHIA.